L 40

Question 1

What does VTE stand for?

Answer 1

Venous thromboembolism. (Vain)

Question 2

What are the 2 types of VTE?

Answer 2

Deep vein thrombosis (DVT)

Pulmonary embolism (PE)

Question 3

Where do the clots form in VTE?
Where do they form?
What colour are these clots/what are they rich in?

Answer 3

Clots form in the vein due to blood stagnation/in vessel wall/ cause valve damage
They are fibrin rich clots, aka ‘red clots’

Question 4

What is the difference between Red and White clots?

Answer 4

Red clots: fibrin rich. Caused by stagnation of blood

White clots: platelet-rich. Caused by atherosclerosis.

Question 5

Risk factors for VTE:

What are the complications of VTE?

Answer 5

Age
History of VTE
Venous stasis (illness, surgery, obesity, varicose veins)
Vascular injury (trauma, major surgery e.g knee replacement)
Hypercoagulopathy
Drugs (e.g estrogen, tranexamic acid)

chronic Venous insufficiency (eg. oedema cellulitis venous ulceration)

Question 6

What are some causes of hypercoagulopathy x3

Answer 6

Cancer, abnormal clotting factor concentration, pregnancy

Question 7

What is DVT? and PE?

Signs and symptoms of DVT

What is the test of DVT ?

Answer 7

DVT is a thrombus is blocking a deep VAIN(ex:abdomen, leg)

PE is a thrombus or embolus blocking the ARTERY

• Unilateral(one side) leg swelling (edema, pain, warmth, erythema)
• Positive homans sign (pain when ankle is dorsiflexed)
• Clot detectible through Duplex ultrasound.

D-dimer Test (product of fibrin breakdown, elevated when there is a clot)

Question 8

Signs and symptoms of PE

Answer 8

• Cough, chest pain/tightness, palpitations.
• Dizziness
• Elevated D-dimer
• May be preceded by signs and symptoms of DVT
• Clot detectible via ventilation/perfusion scan or CT scan

Question 9

Orthopnoea

Answer 9

Shortness of breath when lying down

Question 10

Haemoptysis

Answer 10

Coughing up blood

Question 11

Principles of VTE treatment x5

Answer 11

1. Detect VTE early
2. Prevention/prophylaxis(action taken) of events and complications early
3. Prevent further clots/emboli
4. concentrate on Re-vascularise/re-perfuse
5. Avoid adverse drug treatment effects (e.g bleeding!!)

Question 12

What drug class breaks down the thrombus?

Answer 12

Fibrinolytics

Question 13

which drug class prevents the propagation of a thrombus and long-term disease recurrence?

Answer 13

Anti-coagulants

Question 14

What would be the Immediate treatment for hemodynamically unstable PE patients?

What is the test available for PE clot?

Answer 14

IVF, O2, vasopressors, ventilation and may require resuscitation before treatment for the PE itself

Ventilation /perfusion V/Q
or CT scan

Question 15

Immediate treatment for PE patients (after haemodynamic stabilisation)

Answer 15

Alteplase 10mg IV bolus over 20 mins + 90mg IVI over 2 hours

Question 16

What is alteplase?

Answer 16

A recombinant tissue plasminogen activator (rt-PA)Short term treatment for VTE (~5 days)

Question 17

What does UFH bind to and what does LMWH bind to?

Answer 17

UFH: Thrombin and Xa and IIa

LMWH: Thrombin and Xa

Question 18

VTE treatment long term (3month+)

Answer 18

Varies dependent on risk factors related to clotting.

• Warfarin: 3-5mg OD then adjusted as per INR
• Dabigatran: 150mg bd. Adjust if elderly or Crcl impaired as can’t monitor.
• Rivaroxaban (+ apixaban but not yet funded): 15mg bd for 3 weeks then reduce the dose to 20mg OD

Question 19

Which medicines can you not monitor for VTE?

Answer 19

Dabigatran and rivaroxaban

Question 20

pros and cons of Warfarin and NOACs?

Answer 20

Similar effectiveness, all have a narrow therapeutic window.

Warfarin: is cheaper, slower onset of action, longer t0.5 (more forgiving), can be measure so can be guided by INR, can be REVERSED by VitK

NOACs: expensive, faster onset of action, Can not be monitored required, the effect can’t be readily reversed ($$$)

Question 21

What is heparinisation?

Answer 21

Giving heparin to a patient. That can be Sometimes by infusion.

Question 22

VTE is an important medical condition with potential consequences and what are they?

With what we can treat DVT and PE with anticoagulants?

During VTE therapy what are the risks?

What type of therapeutic window do anticoagulants have? do they need monitoring?

Answer 22

Thrombus/embolism formation inside a vein, and is a fibrin-rich red clot.

Both DVT and PE are treated with anticoagulants acutely and long term. But Some PE patients would also require thrombolytics

risk of bleeding and the risk is even higher when this therapy is thrombolytics.

All anticoagulants have a narrow therapeutic window. Adherence and monitoring/recognition of adverse effects is very important.

Question 23

With what we can measure Unfractionated heparin

Answer 23

aPTT test

and then according to result, we adjust the dose.

Question 24

With what we can measure Low Molecular weight heparin? Ex: enoxaparin

Answer 24

Anti-Xa test

Question 25

How to give UFH heparin dose?

Answer 25

IV bolus or infusion

Question 26

How adjust LMWH heparin dose?

Answer 26

according to CrCL if it is low

Question 27

What based on treatment DURATION based on what for Thromboembolism?

Answer 27

BAsed on risk factors , site of cloth, risk factors, and whether it was provoked

Question 28

What would be the initial dose of warfarin?

Answer 28

OD start with 3 to 5 mg

then adjust the dose according to the INR result

Question 29

Does Apixaban is funded?

Answer 29

NO